NURSE-3101 Lecture Notes - Lecture 1: Ear Drop, Cotton Swab, Chlorhexidine

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1 Sep 2016
Chapter 30 Hygiene
Personal Hygiene Practices
Cultural practices as to bathing and cleanliness.
Necessary care based on patient’s disease process
oFoot care for patient with diabetes
Limits on self-care based on immobility, weakness, dizziness, pain.
Personal preferences.
See assessment of hygiene practices pages 904--905.
Nurse individualizes hygiene based on all of the above.
Physical Assessment Related to Hygiene
Bath time is a great time to assess your patient!
oDoes the patient have the muscle strength, range of motion, and balance to do
their own hygiene?
Best time to assess the skin is during the bath.
Other relevant assessments
oOral cavity, eyes, ears, nose, hair, nails, feet, and perineal area.
Providing Scheduled Hygiene Care
Early morning care
oWash face/hands; oral care; prepare for breakfast.
Morning care (a.m. care)
oOral care; bath; hair care; dressing; change bed linens; tidy bedside area.
Assist patient as needed (self-care, partial care, complete care).
As needed care (prn care)
oOral care P. C.; hygiene prn; change gown/bed linens prn.
Bedtime care
oToileting; wash face/hands; oral care; back rub.
Bathing Individualized to Patient
oAmbulatory; able to tolerate; shower clean and safe (non-skid mat); if weak, sit on
shower chair; use hand-held shower head; safe water temperature.
Tub bath
oClean tub; assist into tub.
Bed bath
oPatient performs as much of bath as possible; Nurse assists with legs, back, et
oBag bath (disposable bath).
Provide for safety; call light in reach; don’t leave confused patients alone.
Skin Care
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Chlorhexidine gluconate
oAdd to bath water or in pre-packaged wash cloth.
oReduce hospital-acquired infections.
Topical emollient agents (moisturizers)
oLotion, cream, gel, ointment. Hydrate skin. Apply after bath. Apply bid.
Skin barrier products
oCreams, ointments, films.
oProtect skin from excessive moisture (incontinence of feces or urine).
Massaging the Back
Relieves muscle tension; promotes relaxation; improves sleep.
Takes about 4—6 minutes; warm lotion in hands before use; patient prone (or side-lying);
use slow, continuous strokes shoulders to buttocks.
oOpen skin lesions on back; back surgery; fractured ribs.
Oral Hygiene
May be necessary every 1—2 hrs. Brush/floss twice daily.
Oral care with oral care swab moistened with normal saline.
oCommercial mouthwash ok. If stomatitis use saline or prescription mouthwash
with local anesthetic added (e.g., oncology patient).
oRemove at bedtime. Store in labeled denture cup filled with water. May clean by
brushing or with commercial preparation. Wear gloves. Hold over basin/sink
lined with towel.
Handle carefully. Don’t drop and break! Expensive to replace! Careful with bed linens
and meal trays!
Oral Care of Unconscious Patient
Problem: could aspirate water used for oral care.
Have suction available.
Place patient on side.
Nurse wears gloves.
Use mouth care swab moistened with water/normal saline/provided solution.
Gently swab teeth, gums, roof of mouth, inside cheeks.
Gently swab and clean the tongue.
Don’t use too much liquid that could be swallowed or aspirated.
Don’t stimulate gag reflex/vomiting.
Suction if needed.
Oral airway if unable to keep mouth open.
Get assist of second person if needed.
Don’t stick your finger in there!
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